Research has shown that the risk of dying from an acute myocardial infarction (AMI) has been steadily decreasing across the United States in recent years. Despite this improvement, there is still substantial variation in 30-day risk-standardized mortality rates (RSMRs) from hospital to hospital. To investigate the causes of variation with RSMRs in these patients, my colleagues and I conducted a cross-sectional survey of 537 hospitals to see what strategies they employed. Published in the May 1, 2012 Annals of Internal Medicine, our findings were combined with data from CMS to determine the links between hospital strategies and mortality rates.
5 Key Hospital Strategies for AMI
According to our analysis, five hospital strategies were associated with a clinically important reduced risk of death for patients hospitalized with an AMI:
1) Monthly meetings: Holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital was associated with a 0.70 percentage-point decrease in the RSMR.
2) Cardiologists on site: Always having cardiologists on site lowered the RSMR by 0.54 percentage points.
3) Problem-solving culture: Fostering an organizational environment in which clinicians are encouraged to solve problems creatively lowered the RSMR by 0.84 percentage points.
4) Cross-training nurses: Avoiding cross-training nurses from ICUs for the cardiac catheterization laboratory lowered the RSMR by 0.44 percentage points.
5) Dual champions: Having both physician and nurse champions lowered the RSMR by 0.88 percentage points.
Using all five of these strategies was associated with more than a 1% decrease in 30-day RSMRs when compared with hospitals that used none of the strategies. Only six of the hospitals reviewed in our analysis used all five strategies, but these institutions had an average RSMR of 14.3%. Conversely, 15 hospitals employed none of the five strategies, and the average 30-day RSMR was 15.9% at these institutions.
Easily Implemented AMI Strategies
Fewer than 10% of hospitals reported using at least four of the five strategies. That said, most of the five strategies associated with lower RSMRs for AMI do not require much in the way of additional resources. They do, however, require new ways of working across disciplinary and organizational groups. For example, having cardiologists on site at all times may be impractical for many institutions. This problem could be alleviated by involving pharmacists in the course of care for AMI patients during rounds.
It’s important to adapt coordination and planning within each hospital based on its specific needs when caring for patients hospitalized with AMI. All constituents should meet regularly to improve communication and articulate strategies that will increase collaboration within the hospital.
Readings & Resources (click to view)
Bradley EH, Curry LA, Spatz ES, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Intern Med. 2012;156:618-626. Available at: http://annals.org/article.aspx?articleid=1134648.
Davidoff F. Is every defect really a treasure? Ann Intern Med. 2012;156:664-665.
Bradley EH, Herrin J, Curry L, et al. Variation in hospital mortality rates for patients with acute myocardial infarction. Am J Cardiol. 2010; 106:1108-1112.
Drye EE, Normand SL, Wang Y, et al. Comparison of hospital risk-standardized mortality rates calculated by using in-hospital and 30-day models: an observational study with implications for hospital profiling. Ann Intern Med. 2012; 156:19-26.
Krumholz HM, Wang Y, Chen J, et al. Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006. JAMA. 2009; 302:767-773.
Bradley EH, Herrin J, Mattera JA, et al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care. 2005;43:282-292.